Medical Form Medical Form Name * Email Address * Phone Number * Address * Business Address * Nationality inc. res/dom * Date of Birth * Current Age * Children’s Name’s & Dates of Birth Are You Pregnant? * Yes No Marital Status * SingleMarried– Are You In Good Health? * Yes No Occupation * EmployedSelf Employed Basic Annual Income * Additional Income * Do You Currently Receive Any Benefits (please detail cover levels)? * Business Mileage Per Annum * Responsibilities? * Manual Work? * Height * Weight * Waist Size * Dress Size * Within the last 12 months any unintentional or unexplained weight loss? * Yes No Do you smoke or have you smoked within the last 12 months? * Yes No Type and amount smoked per day? * How long since last smoked? * Alcohol units per week: * Type of alcohol drunk * Alcohol drunk at weekend, weekday * Has a medical professional suggested you reduce your alcohol consumption? * Yes No Any recreational drug use in the last 10 years: such as cannabis, ecstasy, cocaine, methadone, heroin, anabolic steroids * Yes No In last 5 years have you spent more than 90 days overseas: If so, in which countries * Do you take part in any hazardous pursuits or pastimes? Sports, Aviation, Horse Riding, Caving, Climbing, Extreme Sports * How many times a week do you exercise for at least 30 minutes (brisk walk/gardening)? * Banned from driving, involved in a road traffic accident that was not your fault? * Yes No Do you ride a motorcycle? * Yes No If you are human, leave this field blank. Send
